When a System is not a System

The following post appeared on my blog in March 2008. I recently Twittered the link and got a new surge of interest. Obviously it is still relevant to today's situation.

Much is being said of the healthcare system during this election
year. Solutions to its ills are plentiful - ranging from socializing
medicine to allowing "the market to take care of things." Yet with all
of the pundits' self-confident analysis as to the real problem with our healthcare system, one fact is almost never mentioned: it is not a system.

The word system is defined as:

(1) A group of interdependent items that interact regularly to perform a task.

Healthcare, is, in fact a group of entities that work largely independently and often against each other. Here is what I mean:

Primary Care Physicians - Loners who usually don't hear
anything when their patients are in the ER or at the specialist. They
are increasingly isolated from the hospital (by using hospitalists).
Pushed around by insurance and now a dying breed.

Specialists - Cozy with the hospitals in the past. Many now
do procedures in their office or surgery center they have interest in
(so they get some of the money the hospitals were making off them).
Managed care has forced all referrals to go through PCP's, so they
seldom communicate with each other.

Emergency Departments - Where patients go when they can't
find a PCP. High cost due to CYA (ordering extra tests to protect
themselves since they don't see patients back), so insurance companies
want everyone to avoid them. PCP's and specialists dump on them when
too busy.

Hospitals - They have made big money off physicians for
years, now mostly expensive patients are hospitalized. PCP's are given
P4P bonuses for decreasing revenue of hospitals (in theory, at least).

Insurance Companies - The great Satan. The only thing
unifying the other parties is their hatred of the insurance industry.
The goal of insurers is to maximize shareholder value at the expense of
all other parties.

Ivory Towers - Academic medical centers are generally huge
money losers that think that any physician outside of their hospital is
a bad doctor and other hospitals are far inferior. Physicians in ivory
towers are sheltered from reality by not having their salary really dependent on insurance. They are necessary for training of new physicians.

Patients - Patients are the only thing #'s 1-6 have in
common. They assume the other parties are working together, but this is
rarely true. They are hence the only real link between disparate
information systems of the other players in healthcare. Oh yes, they
are the ones for whom the others exist (even though it usually is
assumed the opposite is true).

Here are some common misconceptions about American medicine:

Doctors and hospitals are on the same side. This is
absolutely false. Hospital administrators are generally frustrated with
physicians and physicians feel that hospitals are making money off them without a return for the physician.

Everyone likes Medicare. I have heard pundits actually say
that somehow a "Medicare for all" would be a good thing. Medicare is
the low-water mark for reimbursement for physicians who have not given
it up completely. We have a discount plan for self-pay patients in our
city. To give a really bargain price, we agree to charge them only 10% above that which Medicare charges. The system would fall apart if "Medicare for all" happened because nobody would stay in medicine.

We know what is going on with our patients - Nobody has the
big picture (except perhaps the patient). Specialists don't know why
patients are referred; PCP's often don't know what is going on in
specialists' offices, in the ER, or in the hospital. Medication lists
changed in one location are frequently not changed in others. It is
really incumbent on the patient to fill in these information gaps.

A very large proportion of the money in our system goes to the waste
that is a result of the fact that it is no system. Tests are
duplicated; patients are shuttled around trusting someone knows what is
going on, when they are probably the ones who know the most; doctors
are not working together and hospitals are working against doctors;
insurance companies have lots of information, but use it as leverage to
avoid having to pay. It is chaos. It is expensive chaos.

Any steps that are taken in reforming our "system" must first
address this chaos. How can that happen? I am not sure, but my vote
would be for the two main parties: patients and doctors, to get on the
same page.